AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.
A recent ruling by the Australian Financial Complaints Authority (AFCA) has affected a woman’s critical illness claims, as her diagnosis came within mere days of her policy's eligibility period drawing to an end.
The woman was diagnosed with cancer in her right breast on October 5 of last year, followed by the discovery of cancer in her left breast eight days later. She filed claims under her critical illness policy that she had obtained on July 17.
However, TAL Life, her insurance provider, rejected the claims based on the policy's three-month qualifying period for cancer coverage.
In its ruling, AFCA noted that the policy had provisions to potentially waive the qualifying period if the policyholder could prove they were insured either under a previous TAL policy or by another insurer for the same events, right before their new coverage commenced.
The claimant contended that she had cancer coverage through an insurance policy provided by her husband's employer. She presented a letter from the employer affirming that she was covered under a "life, accident, critical illness, and medical insurance" scheme from August 2020 until June last year. Additionally, she showed documentation indicating her husband’s policy did include critical illness coverage for spouses, encompassing cancer.
While AFCA accepted the availability of this cancer coverage, it was not convinced that she held such coverage "immediately before the current policy began." It also noted she had failed to disclose her previous insurance when applying for the new policy with TAL Life.
"There is no information before me about the extent of the critical illness cover the complainant had, if any, through her husband's employer’s insurance arrangements," AFCA’s ombudsman stated.
"Furthermore, it appears that any cover she might have had ceased about a month before the new policy started. I am not convinced there was 'continuity of cover' as suggested by the complainant."
The ombudsman expressed AFCA’s sympathy towards the claimant, especially given that the diagnoses occurred "very close to the end of the qualifying period." Nonetheless, he emphasized that there was no valid reason for the qualifying period to be dismissed.
"The qualifying period is reasonably short and its existence is not unjust. These terms are part of all insurance policies and they draw necessary boundaries. The enforcement of these terms is not inherently unfair," the ombudsman elaborated.
For a more detailed account of the ruling, refer to the original report by AFCA.
Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.
Recent insurance industry reporting has again put cyber risk in front of small businesses, with a clear message for trade operators: digital exposure is no longer limited to office-based companies. Many electricians, plumbers, builders, landscapers and subcontractors now rely on cloud quoting tools, job management apps, online banking, electronic invoices and customer databases to keep work moving. - read more
The latest catastrophe-focused commentary from Australia’s general insurance sector has arrived with a practical warning for trade businesses: severe weather is no longer a once-in-a-while planning issue. Storms, floods, hail, bushfire and damaging winds are continuing to influence claims volumes, repair costs, underwriting appetite and premium pressure across the market. - read more
ASIC’s continuing focus on insurance pricing has delivered another reminder that renewal documents deserve close attention, especially for tradies managing several policies across their business. Recent regulatory action against an insurer over alleged pricing and discount failures reinforces a practical point: the final premium shown on a renewal notice may not always tell the full story about how that amount was calculated. - read more
APRA’s latest general insurance data has again highlighted a point many Australian tradies are already feeling at renewal time: a healthier insurance sector does not necessarily translate into simple or immediate premium relief for small businesses. While insurers continue to operate with stronger capital buffers and improved underwriting discipline, the costs sitting behind many policies remain under pressure. - read more
The national ban on engineered stone has shifted from a regulatory headline into a practical operating issue for Australian trade businesses. Since the ban began in July 2024, regulators have continued to emphasise that uncontrolled work with crystalline silica can expose workers to serious and irreversible illness. For builders, stonemasons, kitchen installers, tilers, demolition contractors and renovators, the message is clear: compliance is no longer something to deal with only when a job looks high risk. - read more
Being a tradesperson in Australia comes with its own unique set of risks. Whether you're an electrician, plumber, carpenter, or builder, having the right insurance coverage is crucial for protecting your livelihood and your peace of mind. Without adequate insurance, you could be financially devastated by accidents, theft, or property damage. - read more
Insurance is a critical component for tradespeople in Australia, providing financial protection against a range of risks that can significantly impact your livelihood. Adequate insurance coverage ensures that you are protected against potential liabilities, damages, and unforeseen circumstances that could otherwise lead to substantial financial losses. - read more
Trade insurance is an essential aspect of running a successful trade business in Australia. Whether you are a carpenter, electrician, plumber, or any other type of tradesperson, having the right insurance coverage protects you from unexpected risks and liabilities that could otherwise derail your operations. - read more
Budgeting is one of the most crucial aspects of running a small trade business. Without a proper budget, it's easy to lose track of your expenses and revenues, leaving you in a financial mess. This can be especially challenging for small trade businesses where margins are often tight, and a minor miscalculation can lead to significant issues down the line. - read more
In the world of trades, having the right financial products can make a significant difference in managing your business effectively. Whether you're a plumber, electrician, carpenter, or any other type of tradesperson, financial products such as insurance, loans, and savings accounts play a crucial role in protecting your livelihood and ensuring sustainable growth. - read more
Knowledgebase
Reinsurance: Insurance that an insurance company purchases from another insurance company to mitigate risk.
No comments yet. Be the first to share your thoughts.